Table 3

Summary of interventions in improvement phase

PDSA	Plan	Do	Study	Act
KMC chairs for comfortable position	To try different chairs for at least 2 hours in the morning shift for 5 days by different mothers	A visitor chair was available. Inclined plastic chair and convertible lounge chair one each, arranged from a donation. Mother tried each chair for 2 hours and feedback was taken by the on-duty nurse over 5 days	Lounge chair provided the most comfort, followed by the inclined chair and then visitor plastic chair the least. Lounge chair added more comfort, but, there was a fear of fall back. Testing on a small scale prevented the waste of resources. Early post-natal (<7 days) mothers were not happy with an inclined plastic chair.	Adapted the idea, and 12 inclined plastic chairs arranged for mothers.
	To check which chair is more comfortable for early postnatal (<7 days) mothers with episiotomy and lower segment caesarean section (LSCS) for 2 days	The on-duty nurse assisted one mother each in the morning shift for KMC on all three types of chairs for 2 days	The pain increased in an inclined position. Mothers reported less stretch on stitches on the visitor chair. Acceptable for not more than 1 hour	Adapted the idea. Visitor chairs kept for early postnatal mothers
	To check if a bed with a backrest is more comfortable for early post-natal mothers. In all shifts for 2 days	Borrowed one bed with backrest and on-duty staff nurse assisted one post LSCS and one post episiotomy mother for KMC in one shift each over 2 days.	Comfortable for all KMC givers, including early post-natal mothers. The bed occupied more space. (7×3 feet) (equivalent to three inclined plastic chairs) Need for separate KMC Ward identified. Not possible in post-natal wards as mothers discharged earlier due to overcrowding.	Abandoned the idea due to lack of space. Demand for a separate KMC ward escalated to the authorities
KMC tools for holding the baby	To check the locally available binder cloth is useful for holding the baby in KMC position in morning shift for 2 days	A binder cloth of 1 square metre size was tried on one mother by the on-duty staff in one shift	Mother had to wear a gown over it for privacy. She could not tolerate the binder cloth due to heat and humidity. Dedicated KMC bag needed	The idea abandoned
KMC tools for holding the baby	To design and customise KMC cloth bag for LBW baby in over 7 days	The tailor stitched the KMC bags as per mothers’ requirement, nurse’s suggestions and baby’s size to support the head, neck and back, padding for comfort, and strings for safety. Modified it thrice in 10 days	The bag design finalised after multiple corrections. Different weight bands. (<1500 g and >1500 g) different colours for customisation. Involvement of all stakeholders, necessary	Idea adapted. Design and two bag sizes finalised

Some of these PDSA were not in the same temporal sequence as displayed in the table. We executed one change idea at a time though more than one is shown in a row in some cases in this table. Mother and care givers are used interchangeably as both are KMC givers.
KMC, Kangaroo Mother Care; LBW, low-birth weight; PDSA, Plan-Do-Study-Act.